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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804022
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:47:27 PM

Document Has Been Signed on 06/20/2024 04:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:OAKMONT OF NOVATOFACILITY NUMBER:
216804022
ADMINISTRATOR/
DIRECTOR:		RIC PIELSTICKFACILITY TYPE:
740
ADDRESS:1465 S. NOVATO BLVD.TELEPHONE:
(628) 215-1200
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 118CENSUS: 78DATE:
06/20/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Executive Director, Ric PielstickTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10:00AM to conduct a non-compliance inspection. LPA followed up on the following areas which were initially addressed during a non-compliance meeting dated 07/21/2021. LPA met with Executive Director, Ric Pielstick.

Medications: Facility had residents with unlocked medications in their possession who were not allowed to store and/or dispense medications according to physician's reports on file. During tour of Assisted Living tour, LPAs observed an unlocked cabinet in R1s apartment, which contained PRN medications. LPAs confirmed that R1 was allowed to dispense their own medications per their physicians report.

Prohibited Conditions: Facility retained a resident with a prohibited condition. 10 of 10 files reviewed did not have evidence of any residents being retained with a prohibited condition.

Timely Medical Attention: Facility failed to seek timely medical attention.
LPA reviewed incident reports and confirmed that facility has been seeking timely medical attention.



Medical Assessments: Facility failed to ensure that resident's medical assessments/physician's report is complete as required. LPAs reviewed 10 resident files that had all required documents.

Resident Records: Facility wasn't able to provide CCLD with pre-appraisals for resident's files that were reviewed. LPAs reviewed 10 resident files that had all required documents.



Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: OAKMONT OF NOVATO
FACILITY NUMBER: 216804022
VISIT DATE: 06/20/2024
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Continued from LIC809

Staffing: Facility memory care didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs.
LPAs reviewed staffing schedules for both Memory Care and Assisted Living. LPAs reviewed staff training records which indicated staff are receiving 20 hours of annual training as required per regulation.

Facility Food Services: Facility kitchen area was toured by LPAs and Chef. LPA found that perishable foods were stored in covered containers, and the refrigerator and freezer were at a temperature within regulation. LPAs observed dry goods in boxes on the floor in walk in closet. Chef confirmed that staff was in the middle of reorganizing since their previous chef was terminated.


Reporting Requirements: Facility failed to report refusal of medications, 911 calls, suspected abuse, etc. Incident reports reviewed revealed that facility has been reporting timely.

No deficiencies cited during inspection.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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